Knowledge of RED-s burst onto the sports scene this Fall with a bombshell revelation about the inner workings of The Nike Oregon Project and its Head Coach, Alberto Salazar. The Nike Oregon Project was a long-distance running group started in 2001 by Nike. Initially, it trained world-class American runners like Galen Rupp and Jordan Hasay but later expanded to include international runners like Mo Farah. More on the Oregon Project can be found in this Runner’s World article from October 2019.
This fall, after a storied run, The Nike Oregon Project came to an abrupt end after Salazar, was banned for doping violations. After this ban, a female athlete, Mary Cain, came forward to outline in a New York Times op-ed what she reported was the persistent promotion of unhealthy weight goals and disordered eating practices by Salazar.
Unfortunately, this desire for extreme lightness to gain performance benefits is not uncommon. It can be seen across a range of body-conscious sports from gymnastics and running, to ski jumping and lightweight rowing. Understanding and recognizing Relative Energy Deficiency in Sport, or RED-S, can be helpful for coaches, athletes, and anyone supporting an athlete to ensure a healthy outcome for those at risk.
What is RED-S?
Previously, RED-S (or Relative Energy Deficiency of Sports) was known as the Female Athlete Triad. The term RED-S was coined by health professionals after it was recognized both males and females are affected by energy deficiency in sport.
Athletes require Calories to meet their bodily processes and activities of daily living as well as to support the energetic demands of their sport. RED-S occurs when an athlete does not eat enough to fuel both their bodily needs and their exercise needs. This results in low energy availability and occurs because nutritional intake is too low to fuel activity and, or, their energy expenditure is excessive (1).
While the practitioners and coaches know what to look for, identifying insufficient eating in athletes can be challenging for several reasons. Firstly, an athlete may be eating what appears to be sufficient, but it is not enough to fuel their basic needs plus the excessive demands of their activity. Secondly, athletes can mask disordered eating patterns through their daily fitness regimes which may require that they eat at a different time than the rest of their family. And finally, initial weight loss may appear to be in line with body composition change goals.
RED-S encompasses a spectrum of eating behaviours including disordered eating patterns and eating disorders. The prevalence of eating disorders in male and female athletes is 20% higher than in non-athletes (2). Even so, it is important to understand that RED-S can also occur unintentionally as a by-product of high training demands without the concurrent increase in food intake. There is a high prevalence of RED-S in athletes who do not exhibit disordered eating (3). As such, in many cases, education and knowledgeable support from nutrition experts is the key to prevention and treatment.
How does RED-S affect athletes?
For young athletes, the primary concern is that with RED-S, they eat insufficient Calories to meet the demands of growth and development (1).
For all athletes, eating inadequately affects both performance and exercise recovery. Initial improvements in performance as weight drops gives way to poor results. These performance decrements are likely due in part to poor recovery and illness that affects the quality and duration of training or results in lost training opportunities. Athletes with RED-S have more colds and stomach infections. RED-S also affects bone health and increases the risk of broken bones, fractures, and osteoporosis. And, RED-S can result in hormone changes which may lead to the loss of periods within women (1).
How to recognize signs of RED-S?
Common signs of RED-S include:
- More often or longer-lasting sicknesses
- Loss of periods or irregular periods
- Decreased performance
- Stress fractures in women (1)
How to prevent RED-S?
Athletes must prioritize eating enough food, and enough carbohydrate Calories around exercise to prevent the development of RED-S. These are some methods of reducing the risk of RED-S by eating calories:
- Always have food on hand. Pack your training bag with non-perishable snacks.
- Eat small snacks during activity if exercise persists for longer than 1 hour. For more snacking ideas see our previous blog.
- Eat every 3-4 hours to maintain energy and fuel growth and development.
- Eat foods that are healthy and contain lots of Calories on practice days. Examples include:
- Smoothies with fruit and dairy, nuts and/or seeds.
- Starchy foods like pasta and potatoes.
- Eat meals that are higher in fibre like leafy greens on rest days.
RED-S is a serious disorder amongst athletes that not only robs them of performance but more importantly affects their health and well-being. Treatment and management require a team approach from all members of an athletes training community, including a sports physician, coach, trainers, sports psychologists, and also a sports dietitian. If you are concerned about RED-S, seek the advice of your physician and a sports dietitian to ensure you are eating adequately. See below for additional resources.
- Calorie availability calculator
- Find a physician for RED-S
- Injury prevention in females
This article was written collaboratively by Bianca Cordeiro and Ashley Leone.
Nutrition planning is integral to achieve your optimal athletic performance. Gazelle Nutrition Lab delivers one-on-one or group nutrition counselling and consulting to both recreational and high-performance athletes. In addition, the Gazelle Blog is a free resource for healthy recipes and health tips. Have questions? We’d love to hear from you! Get in touch!
Mountjoy, M., Sundgot-Borgen, J., Burke, L., Ackerman, K. E., Blauwet, C., Constantini, N., . . . Budgett, R. (2018). International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update. International Journal of Sport Nutrition and Exercise Metabolism, 28(4), 316-331. Available from: https://journals.humankinetics.com/doi/pdf/10.1123/ijsnem.2018-0136
Joy E, Kussman A, Nattiv A. 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management Br J Sports Med 2016;50:154-162.
Dudgeon E. Relative energy deficiency in sport (RED-S): recognition and nex steps. Br J Sports Med Blog April 22 2019. https://blogs.bmj.com/bjsm/2019/04/22/relative-energy-deficiency-in-sport-red-s-recognition-and-next-steps/. (Accessed November 20, 2019).